Provider Demographics
NPI:1487022646
Name:FAMILY PRACTICE HEALTHCARE CLINIC/URGENT CARE CLINIC, LLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE HEALTHCARE CLINIC/URGENT CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYCIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-868-2831
Mailing Address - Street 1:10 NORTH 3RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:MCRAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055
Mailing Address - Country:US
Mailing Address - Phone:229-868-2831
Mailing Address - Fax:
Practice Address - Street 1:10 NORTH 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:MCRAE
Practice Address - State:GA
Practice Address - Zip Code:31055
Practice Address - Country:US
Practice Address - Phone:229-868-2831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037111GA261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
202G086558OtherMEDICARE
GA522838074AMedicaid
202G086558OtherMEDICARE